Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July...
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![Page 1: Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July 2014 Charlotte Elder.](https://reader036.fdocuments.in/reader036/viewer/2022062717/56649e395503460f94b2b37d/html5/thumbnails/1.jpg)
Dipstick Screening for Urinary Tract Infection in
Febrile Infants
Journal Club
Tuesday 15th July 2014
Charlotte Elder
![Page 2: Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July 2014 Charlotte Elder.](https://reader036.fdocuments.in/reader036/viewer/2022062717/56649e395503460f94b2b37d/html5/thumbnails/2.jpg)
![Page 3: Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July 2014 Charlotte Elder.](https://reader036.fdocuments.in/reader036/viewer/2022062717/56649e395503460f94b2b37d/html5/thumbnails/3.jpg)
Background
• SBI occurs in 10-15% 1-90 day olds
• UTI commonest cause SBI
• Utah– Neonates – FSS and empirical Abx
– >28/7 – screen tests and ? admit
• NICE – Infants <3/12 – urine testing
– Urgent M+C for infants <3/12
– Dipstick for children >3yrs
![Page 4: Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July 2014 Charlotte Elder.](https://reader036.fdocuments.in/reader036/viewer/2022062717/56649e395503460f94b2b37d/html5/thumbnails/4.jpg)
SCH guideline (7.1)
“Children younger than 2 years of age:
– Urgent microscopy and culture preferred method for diagnosing UTI
– Dipstick analysis may be unreliable”
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• Nitrites– Urinary micro-organisms reduce nitrate to nitrite– Nitrate needs to be in contact with bacteria for “some time”– Not all bacteria – Too quick in under 2s?
• Leucocytes (LE)– LE enzyme contained in WBC– UTI not the only cause of pyuria
• Evidence base?
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Systematic review
• 6 studies
• Dipstick signif less good in < 2yrs
• LR
– +LR 38.5 vs 7.6
– -LR 0.13 vs 0.34
Mori et al. Acta paediatrica 2010;99:581-584
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The Clinical Question
Population Children less than 2 years with suspected UTI
Intervention Dipstick urine testing or urine microscopy
Comparison Urine culture
Outcome Accurate diagnosis of UTI
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![Page 9: Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July 2014 Charlotte Elder.](https://reader036.fdocuments.in/reader036/viewer/2022062717/56649e395503460f94b2b37d/html5/thumbnails/9.jpg)
Aim
Comparing performance of urine dipstick alone with
urine microscopy and with both tests combined as
a screen for UTI in febrile infants aged 1 - 90 days.
![Page 10: Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July 2014 Charlotte Elder.](https://reader036.fdocuments.in/reader036/viewer/2022062717/56649e395503460f94b2b37d/html5/thumbnails/10.jpg)
Methods
• Retrospective observational study
• July 2004 – December 2011 (7.5 yrs)
• Multi-centre (23 hospitals)
• Same diagnostic equipment and database
• Patients identified from database
– Febrile infants and age
– Reason for visit
– Admitting diagnosis
– ICD-9 and coding
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Methods
• Age 1-90 days
• Catheterised urine – 10mls
– Dipstick
– Microscopy of centrifuged urine
– Culture
• Medical records r/v if UTI but dipstick negative for
outcome (29-90 days)
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Definitions - cultures• Positive for UTI
– ≥1 pathogen
– ≥50,000 CFU/ml (half the “classic” definition)
• Negative for UTI– No bacterial growth
– Growth of contaminant only
• <105 CFU/ml common skin GU flora
– Multiple bacteria each <105 CFU/ml
• Equivocal– Urine pathogens 10,000-49,000 CFU/ml
– Excluded from analysis
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Definitions – dip/micro/combo
• Positive for UTI - dipstick
– LE positive
– Nitrite positive
– ≥ trace
• Positive for UTI - microscopy
– >10 WBC per hpf
– ≥ 1 bacteria per hpf
• Positive UTI – combined
– Positive dipstick OR
– Positive microscopy
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Results
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Study flow chart
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Results
6394 febrile infants
770 UTI (12%) 5624 no UTI
1745 (27%)neonates
4649 (73%)29-90 days old
6394 febrile infants
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p = <0.001
Sensitivity = true positives
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p = <0.001
Specificity = true negatives
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p = <0.001
![Page 21: Dipstick Screening for Urinary Tract Infection in Febrile Infants Journal Club Tuesday 15 th July 2014 Charlotte Elder.](https://reader036.fdocuments.in/reader036/viewer/2022062717/56649e395503460f94b2b37d/html5/thumbnails/21.jpg)
p = <0.001
p = <0.001
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p = <0.001
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Example
• Prevalence in 29-90 day old infants = 11.9%
• 1000 febrile infants
– 119 culture positive UTI
– Dipstick alone
• 90.4% true positive pick up (108/119) – 9.6% false negative
• 6.2% false positive rate (55 of 881)
– Combined urinalysis
• 94.8% true positive pick up (113/119) – 5.2% false negative
• 10.9% false positive rate (96 of 881)
• 8 treated who don’t have UTI for every 1 infant missed
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Critical appraisal
• Does the study address a clearly focused question?
• Did the study use valid methods to address the Qu?
• Are the valid results of the study important?
• Are the valid, important results applicable to our local
population?
• Were all clinically important outcomes considered?
• Are the benefits worth the harms/risks/costs?
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Summary and Conclusion
Good to rule out UTI
CLINICAL BOTTOM LINE
Can dip infants’ urine?